SPITALUL CLINIC C.F.

CONSTANTA AMBULATORIUL DE SPECIALITATE

B-dul I.C. Bratianu nr.35-37, Constanta Tel/Fax: 0241 611 393, email:ambulatcfc@yahoo.com

CERTIFICAT MEDICAL / MEDICAL FITNESS CERTIFICATE

DOCUMENT CONFIDENTIAL / Confidential Document

NUME / Surname

PRENUME / Given Name(s)

DATA NASTERII / Date of birth LOCUL NASTERII /Place of Birth LUNA ZI AN City Country Month Day Year EXAMINAT PENTRU FUNCTIA/ Examination for duty as: COMANDANT/Master OFITER MECANIC/Engineering Officer NEBREVETAT/ Rating OFITER PUNTE/ Deck Officer OFITER RADIO/ Radio Officer ALTELE / Other ______________

INITIALA TATALUI / Fathers initial SEX / Sex Barbatesc Femeiesc Female , Male ADRESA /Applicant Address

EXAMINAREA MEDICALA (PE VERSO CERINTELE MEDICALE) REZULTATELE VIZITEI MEDICALE Medical Examination(See reverse side for medical requirements) State details on reverse side INALTIME/ Height GREUTATE/ TENSIUNE ART/ PULS / RESPIRATIE STARE GENERALA (m) Weight (kg) Blood Pressure Pulse Respiration General Appearance

AUZ / Hearing VEDERE/Vision OCHI DREPT/Right eye OCHI STING / Left eye URECHE DREAPTA URECHE STINGA _________ Right Ear Left Ear FARA OCHELARI/Without glasses ________ _________ _________ CU OCHELARI/With Glasses __________________ _________________ TEST CROMATIC: VERIFICAT DACA TESTUL CROMATIC ESTE NORMAL /Color test type: Book Lantern Check if color ROSU/Red VERDE/Green ALBASTRU/ Blue test is normal : GALBEN/Yellow ORL Head and Neck PLAMINI / Lungs CARDIOVASCULAR / Heart (Cardiovascular) VORBIRE (OFITERI PUNTE SI RADIO)/Speech(Deck Navigational Officer and Radio Officer) Is speech unpaired for normal voice communication? DA NU Yes No

EXTREMITATI / Extremities INFERIOARE/Lower_______________________ SUPERIOARE/UPPER____________________ SUFERA APLICANUL DE VREO BOALA CARE SE POATE AGRAVA LUCRIND LA BORDUL NAVEI, SAU CARE SA-L FACA INAPT PENTRU SERVICIUL PE MARE SAU SA POATE PUNE SANATATEA ALTOR PERSOANE LA BORD? Is applicant suffering from any disease likely to be aggravated by working aboard vessel, or to render him/her unfit for service at sea or likely to endanger the health of other persons on board? DA NU No Yes ESTE APLICANTUL SUB ORICE FEL DE TRATAMEN PRESCRIS/NEPRESCRIS MEDICAL? DA NU No Is applicant taking any non-prescription or prescription medications? Yes SEMNATURA APLICANTULUI/Signature of applicant IN PREZENTA MEDICULUI EXAMINATOR This signature should be affixed in the presence of the examining physician _______________________ SEMNATURA(Applicant Signature) ________________________________ APLICANTUL ESTE DIRECT RASPUNZATOR DE ORICE BOALA CARE ESTE ASCUNSA LA PREZENTUL EXAMEN MEDICAL/The applicant is directly responsible of any illness which is hidden present medical examination. PRIN PREZENTA SE CERTIFICA CA CERTIFICATUL MEDICAL A FOST ELIBERAT PENTRU: ___________________________________ This is to certify that a physical examination was given to:
DATA/Date (NUME / Name of Applicant)

SE CERTIFICA CA APLICANTUL NU ARE BOLI TRANSMISIBILE (SAU VIRUSURI PENTRU BUCATARI) / This applicant NU/No is certified free of communicable disease(or viruses for cooks) DA/Yes MARINARUL ESTE APT /Seafarer is found to be fit / INAPT PENTRU FUNCTIA / Unfit for duty as a: COMANDANT/Master - OFITER PUNTE/Deck Officer- OFITER MECANIC/Engineering OfficerOFITER RADIO/Radio Officer NEBREVETAT/Rating BUCATAR/Cook or Chief CookFARA RESTRICTII/ Without restrictions CU URMATOARELE RESTRICTII/With following restrictions: Numele i gradul medicului/Name and degree of physician _________________________________________________________ Adresa / Address___________________________________________________________________________________________ Autorizaia medical , serie, nr/Physician*s certificate authority no/___________________________________________________ Data eliberarii autorizatiei medicale/ Date of issue of Physician Certificate/_____________________________________________ SEMNATURA MEDICULUI/ Signature of physician _____________________________________________________________ DATA/Date: STAMPILA UNITATII /Official Stamp

CERINTE MEDICALE / MEDICAL REQUIREMENTS Pentru examinarea medicala toti solicitantii trebuie sa detina o atestare a capacitatilor fizice trecuta in Certificatul Medical de Sanatate, completat de un medic autorizat. Dovada examinarii trebuie sa stabileasca faptul ca solicitantii sunt intr-o conditie fizica satisfacatoare in vederea indeplinirii sarcinilor specifice si, in general, au toate aptitudinile fizice necesare pentru indeplinirea cerintelor profesiei de navigator. In plus, urmatoarele cerinte minime trebuie avute in vedere: All applicants for medical examination must have a certificate of physical capacity last in a medical certificate completed by a medical practitioner. Proof of examination must determine that applicants are in satisfactory physical condition in order to accomplish specific tasks, and generally have all the physical skills necessary to meet requirements of the profession of seafarer. In addition, the following minimum requirements to consider: a. Toti solicitanti trebuie sa aiba auzul intact pentru sunetele normale si sa fie capabili sa auda vocea soptita in urechea mai buna la 15 picioare distanta si in urechea mai slaba la 5 picioare (1 picior = 30,5 cm). All applicants must have intact hearing for normal sounds and be able to hear voice whispered in the ear better from 15 feet away and the worst ear at 5 feet (1 foot = 30.5 cm) b. Ofiterii de punte solicitanti trebuie sa aiba (cu sau fara ochelari) cel putin 20/20 acuitate vizuala cu un ochi si cel putin 20/40 la celalalt. Daca solicitantul poarta ochelari el trebuie sa aiba vederea fara ochelari la cel putin 20/160 la ambii ochi. Ofiterii de punte solicitanti trebuie sa aiba, de asemenea, o perceptie normala culorilor si sa fie capabili sa distinga culorile rosu, verde, albastru si galben. Deck officers applicants must have (with or without glasses) at least 20/20 acuity viewing with one eye and at least 20/40 in the other. If the applicant wearing glasses he must to have at least 20/160 without glasses in both eyes. Deck officers applicants must also have a normal perception of colour and be able to distinguish red, green, blue and yellow. c. Ofiterii mecanici si operatorii radio trebuie sa aiba (cu sau fara ochelari) cel putin 20/30 acuitate vizuala la un ochi si cel putin 20/50 la celalalt. Daca solicitantul poarta ochelari, el trebuie sa aiba vederea fara ochelari de cel putin 20/200 la ambii ochi. Ofiterii mecanici si operatorii radio trebuie, de asemenea, sa fie capabili sa perceapa culorile rosu, galben si verde. Engineers and radio operators must have (with or without glasses) at least 20/30 visual acuity in one eye and at least 20/50 in the other. If the applicant wearing sunglasses, he without glasses should have to at least 20/200 in both eyes. Engineers and Radio operators must also be able to perceive red, yellow and green. d. Tensiunea arteriala a solicitantilor trebuie sa fie la o valoare medie, luand in considerare varsta acestora. Blood pressure applicants must be at an average value, taking into account their age. e. Conditii medicale citate mai jos sunt exemple care ar putea justifica restriciile de timp, functie, zona de comer, tipul de nave, sau de supraveghere medicala, sau sa faca aplicantul candidat de a fi, temporar sau definitiv inapt: tuberculoza, hepatita, malarie, sindromul imunodeficienei dobandite (SIDA), enterita, boli cu transmitere sexuala, boli vasculare, boala cardiaca ischemica, angina pectorala, antecedente de tromboza sau bypass coronarian, aritmie; purtator de pacemaker. The medical conditions cited below are examples which might justify restrictions on time, position, trade area, type of ships, or medical surveillance, or render the examinee temporarily or permanently unfit: tuberculosis, hepatitis, malaria, Acquired Immunodeficiency Syndrome (AIDS), enteritis, sexually transmitted diseases, vascular disease, ischaemic heart disease, angina pectoral, history of coronary thrombosis or bypass grafting, symptomatic abnormality of the rate of rhythm; dependence on pacemaker. f. Examinatorul medical trebuie sa aiba n vedere faptul ca nu este posibil a se dezvolta o lista cuprinzatoare de contraindicatii, dar ca aceasta lista poate sa ofere unele indicaii. Ea nu poate lua locul gandirii medicale. Atunci cand se determina a fi apt pentru serviciu pe mare, n cazul persoanelor cu probleme medicale, medicul ar trebui sa analizeze si sa evalueze urmatoarele puncte: (a) timpul critic necesar pentru tratamentul/accesul adecvat pentru ingrijiri de baza pe uscat; (b) gradul de periculozitate al problemei medicale pentru pacient, pentru alte persoane la bord si pentru sigurana navei sau a mediului; (c) riscul actual de declansare a problemei medicale. The medical examiner should bear in mind that it is not possible to develop a comprehensive list of contraindications but that this list may provide some guidance. It cannot replace sound medical judgement. When determining fitness for sea service in the case of persons with medical problems, he/she should consider and evaluate the following points: (a)the critical time needed for treatment/access to appropriate land-based care; (b)the extent of the threat and danger caused by the medical problem to the patient, other persons on board and to the safety of the vessel or the environment; (c)the current risk of occurrence of the medical problem. g. Solicitantii, ofiterii de punte, navigatie si operatorii radio trebuie sa aiba dictia corespunzatoare pentru comunicatii cu o voce normala. Applicants /deck officers, navigation and radio operators must have the diction appropriate communication with a normal voice. h. Solicitantii pentru timonier, nostro, marinar si marinar stagiar trebuie sa indeplineasca cerintele fizice si psihice specifice functiei la bordul navei. Applicants for coxswain, nostro, seaman and seaman trainee must meet physical and mental requirements specific function on board. i. Solicitantii pentru fochist, oiler/motorist, pompagiu, electrician, wiper (stergator cu carpa) trebuie sa indeplineasca cerintele fizice specifice la bordul navei. Applicants for fireman, oiler/biker chicks, pump man, electrician, wiper must meet specific physical requirements on board. DETALII PRIVIND EXAMENUL MEDICAL (a se completa de medicul examinator) DETAILS OF MEDICAL EXAM (To be completed by the examining physician)

Nota: Prezentul Certificat Medical de Sanatate se va elibera in 3 (trei) exemplare, fiecare dintre ele avand calitatea de original, unul pentru marinar, unul pentru angajator si unul pentru medicul examinator Note: This certificate will be issued a medical in 3 (three) copies, of them having the status of the original one for the sailor, one for Employer and one for examining physician.
Acest Certificat Medical a fost emis in conformitate cu Conventia 1946 (ILO nr.73)ILO/WHO/D.2/1997 si STCW pe '95 modificate. This Certificate is issued by a medical examination in accordance with the requirements Medical (Navigator) Convention 1946 (ILOno.73), ILO/WHO/D.2/1997 and the STCW '95 (Standards of Training, Certification & Watch keeping) as amended.

Form MC Issue 01/2013